Routine inspection·January 16, 2024

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced required annual inspection. LPA identified herself and disclosed the purpose of the visit to facility staff and was granted entry into the facility. Co-administrator, Celeste Castro, arrived a short time later. According to the facility’s license, the facility is licensed for six (6) residents, all of whom may be non-ambulatory. Licensee also has a waiver for one hospice resident. During today’s inspection, there were six (6) residents in care, one of whom receives hospice services. The facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by co-administrator, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Doors, windows and screens were present and sinks and toilets were in working order. Hygiene supplies and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate visitation. The facility’s internal temperature was 75 degrees F. Hot water temperature in bathroom sink in a bathroom that is accessible to residents measured at 112.8 degrees F. During the tour of the facility, LPA observed a knife and scissors stored in an unlocked kitchen drawer. Toxic cleaning supplies and bleach were observed in accessible bathroom cabinets, and AJAX cleaner was observed on a resident bathroom sink. No open-faced heaters, pools, or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms and facility telephone were all in working order. A carbon monoxide detector was observed present in the facility; however, the carbon monoxide detector was not in working order. Prior to the end of the visit, a new carbon monoxide detector was delivered to the facility, installed, and observed to be in working order. Fire extinguisher present in the home was serviced within the last 12 months. LPA observed the use of a postural support for Resident 1 (R1) [LIC 811 Confidential Names List]; however, there was no physician’s order maintained for the use of the postural support. LPA interviewed staff and residents. The interviews did not produce any significant licensing concerns. LPA also reviewed staff and resident records/files. Staff who was present and working in the facility at the time of the visit did not have current first aid/CPR training. Medications were stored in a locked cabinet with appropriate labels. Plans of Correction were jointly developed with the administrator. An exit interview was conducted with Celeste Castro to whom a copy of this report, the LIC 809-D, LIC 811 Confidential Names List, LIC 9102 TAs/TV, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.